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Breast cancer Flashcards

1
Q

what is incidence of BRCA1 and 2?

A

1:300-800
- 10-20% of all ovarian and 5% breast cancers associated w/ BRCA 1/2.

BRCA1:
- breast cancer risk 70% (assoc w/ triple neg)
- ovarian cancer risk 40% - RRSO by 35-40

BRCA2
- breast cancer risk 70%
- ovarian cancer risk 20% (occurs later), RRSO by 40-45
- also incr risk prostate, pancreatic, gastric cancer, melanoma.

  • ovarian cancers: endometrioid or high grade serous
  • Chemoprophylaxis: OCPs to decrease ovarian cancer (decreases # of ovulations), tamoxifen to decrease breast cancer for BRCA2.
  • RRSO reduces risk by 80%,, prophylactic mastectomy (decr risk by 90-95%).
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2
Q

What is screening for BRCA1/2?

A

CBE twice/year
- annual MRI at age 25
- annual mammogram and MRI at age 30, alternative q6mo
- ovarian cancer screening: not recommended! but consider CA-125, TVUS, pelvic yearly at age 30-35
- prophylactic mastectomy if done w/ childbearing/age 35)

  • discuss chemoprophylaxis (only for BRCA2)

BRCA1 gene is located on chromosome 17
BRCA2 gene is located on chromosome 13

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3
Q

Who needs genetic counseling and screening?

A
  • hx suggestive of AD cancer syndrome (eg Lynch)
  • BRCA 1/2 mutation in family
  • breast cancer < age 50
  • breast cancer in male, ashkenazi Jew or triple neg hsitology
  • person w/ multiple primary breast cancers
  • concerning fam hx w/ multiple breast cancer, ovarian, pancreatic, prostate cancer
  • any ovarian, fallopian tube or primary peritoneal cancer.

BRCA1/2 in general population: 1:300-1:800. In Ashkenazi Jews its 1:40

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4
Q

What are risk reducing strategies for high risk breast cancer?

A

Raloxifene - 60mg qd
- reduces ER pos breast cancer in POSTMENOPAUSAL
- cholesterol reduction
- incr VTE risk
- 60% reduction in breast cancer
- osteoporosis prevention and tx
- no time limit on tx.

Tamoxifen - BRCA2 carriers w/o mastectomy. reduces ER/PR pos, not good for BRCA1.
- cholesterol reduction, endometrial thickening, vTE risk.
- 50% reduction in breast cancer
- decrease fracture risk
- CAN ONLY USE FOR 10 YRS
-2.5x risk of EIN, geometrical cancer. minimal estrogenization.

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5
Q

What is the differential diagnosis of a breast mass in 30 y/o

A
  • malignancy
  • fibroadenoma
  • breast cyst (simple or complex)
  • fibrocystic changes
  • breast abscess (if breastfeeding or sx mastitis)
  • galatocele
  • fat necrosis
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6
Q

How do you counsel pt with BRCA2?

A
  • discuss incr risk breast cancer (85%) and ovarian cancer (20%).
  • discuss risk of other cancers: melanoma, male breast cancer, prostate and pancreatic
  • discuss breast cancer screening: CBE, mammogram and mRI
  • discuss ovarian cancer screening: not strongly recommended. but Ca-125 and TVUS does not decrease mortality, can increase anxiety with false positives. Can do OCPs if still desires fertility. needs RRBSO by age 40-45
  • chemoprophylaxis w/ tamoxifen (incr risk endometrial hyperplasia nd polyps)
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7
Q

Can you have HRT after a hysterectomy w/ BRCA1/2?

A

Yes, if no breast cancer can have estrogen alone.

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8
Q

What are benign breast lesions
- Non-proliferative

A

(1% incr risk future breast cancer)
Simple cysts
Mild hyperplasia (usual type)
Papillary apocrine change

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9
Q

What are benign breast lesions
- Proliferative w/o atypia AKA fibrocystic changes

A

(1.7% increased risk breast cancer)
1. Fibroadenoma (MOST COMMON CAUSE SOLID BREAST MASS)
——Benign proliferative breast lesions. Tumor w/ glandular and stromal tissues.
——-Risk factors: black race, age 20-30, OCP use before age 20
2 types: simple (no incr risk cancer) and complex (slightly increased risk of cancer. Small (1-2cm) firm well circumscribed mobile mass.
Ddx: US. well-circumscribed homogenous hyperdense lesion, mobile w/ probe. On mammogram - popcorn calcifications
Indications for biopsy?
- can biopsy or short term f/u (3-6mo) w/ repeat US + CBE.
- Size >2.5cm, enlarging, calcifications, pt peace of mind.
When to operate: if pain, concern for cancer, +fam hx breast cancer, questionable biospy results.

Giant fibroadenoma
2. Intraductal papilloma
Moderate hyperplasia
Sclerosing adenosis
Radial scar

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10
Q

What is Atypical hyperplasia?

A

(4% incr risk future breast cancer)
Atypical ductal hyperplasia
Atypical lobular hyerpplasia

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11
Q

What is Lobular carcinoma in situ

A

(7-10% incr risk future breast cancer)

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12
Q

What are categories of mastalgia and causes?

A
  • Cyclical
  • Non-cyclical
  • Extramammary: costochondritis, chest wall trauma, rib fractures, fibromyalgia, herpes zoster, angina, GERD, pregnancy
    Etiologies include mastitis, trauma, thrombophlebitis (Mondor disease), cysts, tumors and cancer.
  • Meds: hormonal meds, antidepressants, anti-HTN, antimicrobial
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13
Q

How is mastalgia evaluated?

A
  • If assoc w/ breast cancer: more likely to be unilateral, intense, noncyclic and progressive
  • CBE to identify discrete or concerning abnormalities and to evaluate chest wall separately from breast.
  • Extrammary mastalgia: constochondritis c/w point tenderness over costochondral junction
  • Duct ectasia, periductal mastitis and inflammatory conditions have mastalgia as primary symptom
  • Breast imaging considered for focal mastalgia not explained by obvious cause (MSK) and if pain is new.
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14
Q

What is Mondor disease?

A

superficial thrombophlebitis of lateral thoracic vein - rare condition causes noncyclic breast pain/tenderness. PE=palpable cord (initial red and tender, linear skin dimpling). Need age appropriate breast imaging to r/o underlying cancer.

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15
Q

How is mastalgia managed?

A

Depends on source of pain. Reassurance if cyclic.
Non-pharmacologic: well fitted and supportive bras. Dietary changes.
Pharmacologic: NSAIDS=primary tx. OCPs NOT proven tx, can try continuous dosage to improve sx.
- Post-menopausaal women w/ mastalgia after initiating HRT can discontinue it or decrease estrogen dose.
If resistant: prescription meds for 3-6 months: Danazol - only fDA approved. Or tamoxifen (SERM) 10mg/day.

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16
Q

How is Duct ectasia diagnosed and managed?

A

Occurs in middle-aged and elderly. Smoking and parity=rF. Usually asymptomatic.
- Clinically as niple discharge, nipple inversion, noncyclic mastalgia or infxn. Doesn’t require surgery, manage conservatively.

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17
Q

What are Birads classification?

A

Birads 0- incomplete need additional imaging
Birads 1- neg (0% chance of malignancy)
Birads 2 - Benign (0% change of malignancy)
Birads 3 - probably benign 0-2% chance
Birads 4 - Suspicious. Categories a,b,c increasing likelihood f malignancy
Birads 5 - highly suggestive of malignancy >95%
Birads 6 - known biopsy proven malignancy.

**Lifetime risk of breast cancer is 12%!
screening protocol: age 40, annual or biannual (shared decision-making), annual CBE.

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18
Q

How is palpable breast mass evaluated?

A

IF < 30 - US. IF no mass on US, low risk cancer, monitor for 1-2yrs w/ PE
If > 30, diagnostic mammogram

History: how long has mass ben there, persistent, any skin changes or nipple discharge? recent trauma, fam hx breast/endometrial/colon Cancer, breast feeding?
Exam: cystic or solid? mobile, smooth or irregular/fixed. Any skin changes, nipple discharge? axillary LAN? examine in sitting and supine position.

19
Q

What is a simple cyst vs complicated breast cyst?

A

simple cyst: no internal septations or mural thickening and birads 2 (benign)

complex cyst: round circumscribed mass, low-level echos w/o vascular flow, BIRADS 3 (probably benign)

20
Q

What is management of simple and complicated cyst?

A

simple: Benign, don’t require aspiration unless bothersome

complicated: Low chance of malignancy. If mass resolves, follow clinically.
- If fluid bloody or mass doesn’t resolve, need image-guided aspiration, core needle biopsy or mass excision.

COMPLEX cyst: cystic and solid components and BIRADS 4-5 : biopsy!!

21
Q

What are options for abnormal findings on imaging:

A

FNA (cytology
core needle biopsy (histology, preferred)
excisional biopsy

22
Q

What are advantages/disadvantages of FNA, core needle biopsy and excisional biopsy?

A

FNA: Small-bore needle, inexpensive, minimally invasive. Disadvantage: requires pathologist w/ special expertise to interpret. Findings often require core needle biopsy

Core needle biopsy: minimally invasive. Large bore cutting needle preferred biopsy method bc few complications and minimizes surgical changes to the breast. Can also place clip to mark lesion undergoing biopsy which is helpful in future imaging/surgeries.

Excisional: if core needle biopsy is nondiagnostic or discordant w/ clinical exam (i.e. BIRADS 4 or 5 AND MAMMOGRAM NORMAL on core needle biopsy).

23
Q

How is atypical hyperplasia found on core needle biopsy evaluate and managed?

A

Surgical excision bc DCIS or invasive cancer detected at time of excision in 10-20% cases
Screening recommendations: annual mammogram, CBE q6-12mo. Annual MRI if women 30+.

Risk reducing therapy: Tamoxifen (pre or post menopausal), raloxifene (post menopausal), aromatase inhibitors (post menopausal). Maintain healthy lifestyle to decr risk breast cancer (Avoid alcohol use).

24
Q

How is lobular carcinoma in situ evaluated and managed?

A

Surgical excision to r/o DCIS/invasive. Screening mammogram and CBE q6-12 mo after age 30.
Risk reducing strategies: same as atypical hyperplasia. Tamoxifen (pre or post menopausal), raloxifene (post menopausal), aromatase inhibitors (post menopausal). Maintain a healthy lifestyle to decr risk breast cancer (Avoid alcohol use).

Also prophylactic mastectomy is option.

25
Q

How is non-milky discharge evaluated and managed?

A
  • breast exam, identify site of nipple discharge, diagnostic mammogram + US

If discharge persistent/reproducible, spontaneous, unilateral, from single duct, serous or bloody- CONCERNING
If multiductal or nonspontaneous (ie expressed only), and exam normal, likely benign

Eval: start w/ US then diag mammo for 30+

If BIRADS 1-3 but abnormal discharge: duct excision. REFER TO BREAST SURGEON. ductogram to find intraductal mass.

26
Q

How do patients w/ inflammatory breast cancer present? How are they managed?

A

Sx: pain, progressive breast tenderness, skin discoloration, firm/enlarged breast.
Exam: edema, peau d’orange, nipple excoriations, ulcerations

Workup: mammogram, US, punch biopsy of breast skin.

27
Q

What is mastitis?

A

2/2 Staph aureus (majority) and group B strep

1-2% in breastfeeding mothers
- presents postpartum week 1-5
- Tx: heat/cold compresses, ibuprofen, acetaminophen. avoid tight-fitting clothing. continue to express milk from both breasts
- Empiric tx for non-severe infix: dicloxacillin 500mg QID or keflex 500mg QID.
- if MRSA risk: Bactrim DS BID or Clinda 450mg TID.

28
Q

Management of mastitis?

A

Dicloxacillin 500mg QID x 7d or keflex 500mg qid. IF allergy, erythromycin 250mg QID.

If not responding, consider beta lactam resistance and substitute w/ augmentin.
If still not improving, change abx to cover MRSA (Bactrim ds BID or Clinda 450mg TID. IV vanc 1g) and order US to rule out abscess
Criteria for inpatient admission: abscess, signs of sepsis, unable to tolerate PO, co-existing immune compromise, recurrent/persistent mastitis

29
Q

How do you manage recurrent scabbing/eczema like changes of nipple?

A

Full-thickness skin biopsy to r/o Paget disease, which is assoc w/ invasive breast cancer or DCIS in 85% of the case.

30
Q

What is the differential diagnosis of postpartum breast erythema?

A
  • Mastitis
  • Clogged milk duct: optimize feeding technique. resolves in 48hr or get US to r/o abscess.
  • Marked engorgement: interstitial edema or excess milk. compresses or tylenol/ibuprofen.
  • Abscess: abx and I&D
  • Inflammatory breast cancer: warm thickened skin w/ peas d’ orange. refer to breast specialist.
31
Q

Pregnant woman w/ breast mass. How do you evaluate?

Antibiotics contra-indicated in pregnancy?

A

Avoid FNA bc false positives. Do core or excisional biopsy

doxycycline (teeth staining), erythromycin (hepatotoxic), chloramphenocol (gray-baby syndrome).

32
Q

What are indications for breast MRI?

A

BRCA pos or 1st degree relative who is BRCA pos
Lifetime risk of breast cancer of 20%
Hx chest radiation btw ages 10-30
Genetic syndromes (Li Fraumini, Cowden, Banyan syndrome or 1st degree relative w/ genetic syndrome)
Atypical hyperplasia and LCIS on biopsy

33
Q

What are radiologic concerns on mammogram?

A

Irregular borders, microcalcifications, new abnormality compared to prior mammogram

34
Q

IF pt w/ tender right outer quadrant of breast, what is concern?

A

ddx: malignancy, fibrocystic changes, fibroadenoma, breast cyst, abscess, galatocele, fat necrosis

  • ddx: mammogram and US
  • any inflammatory finding if pt not postpartum/breastfeeding=CONCERN FOR MALIGNANCY. Can initially treat w/ antibiotics to exclude breast abscess but also get breast surgery consult and biopsy.
    –failure of abx in TRUE mastitis=MRSA and/or breast abscess.
35
Q

What are types of nipple discharge?

A
  • majority spontaneous discharge=benign. unilateral usually 2/2 intraductal papilloma (benign).

Green/yellow - duct ectasia
Purulent - bacterial infection (mastitis or abscess)
Yellow/pink serosanguinous: intraductal papilloma, fibrocystic change
Bloody - intraductal papilloma
clear/watery: CARCINOMA

36
Q

How would you counsel pt with sister w/ newly diagnosed breast cancer?

A
  • minimize breast cancer risk w/ lifestyle changes: weight management, exercise, avoid smoking/alcohol
  • mammograms at age 40 or 10 yr before sister diagnosed.
  • calculate risk score to see if she qualifies for chemoprophylaxis or MRI surveillance
  • get sister tested for BRCA mutation.
  • Chemoprophylaxis if high risk for breast cancer: MUST BE 35+, BRCA pos or high risk on scoring model.
37
Q

What should you do before starting tamoxifen?

A

Screen postmenopausal women w/ TVUS, sonohysterography or office hysteroscopy due to incr risk w/ polyps present BEFORE therapy.

38
Q

What are SERMs?

A

selective estrogen receptor modulator
- tamoxifen
- RAloxifene
- Clomiphine
- Ospemifene: for dyspareunia 2/2 vaginal atrophy of menopause. avoid if breast cancer. oral alternative to vaginal estrogen.
- Bazedoxifene (DuaVee): combo SERM = estrogen for VMS and to decrease risk of osteoporosis.

39
Q

What percent of breast cancer and ovarian cancer are inherited?

A

Breast < 10%
Ovarian < 15%

40
Q

What are contraceptive options in breast cancer patients?

A

Can be hormone-receptor positive so recommend non-hormonal options: copper IUD, sterilization.

If just family hx or BRCA1/2, can have hormonal options. But if personal hx, no hormones.

41
Q

Radiologic findings of concern on mammogram?

A

mass, microcalficiations, new abnormality compared to prior mammogram

42
Q

When is breast MRI indicated?

A
  • BRCA after age 30
  • lifetime risk of breast cancer >20% on Gail model
  • hx chest radiation
43
Q

What is the Gail model?

A

risk assessment tool for pts at high risk for breast cancer
INCLUDES:
- age
- age at menarche
- age at 1st live birth
- #1st degree relatives w/ Breast cancer
- race
- # prior breast biopsies.

if >20%, need breast MRI

44
Q

Advantages of breastfeeding?

Contra-indications to breastfeeding?

A

promotes bonding, weight loss, , fewer unplanned pregnancy, cost-effective, decreased childhood obesity

HIV, active HSV lesion, +TB, alcohol or illicit drug use.

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